Orthoptic Management Of Retinally Mediated Diplopia After Macula-Off Retinal Detachment

Diplopia after macula-off retinal detachment repair may be multifactorial. While ocular motility imbalance is often considered, macular structural alteration and displacement may result in binocular image disparity due to altered corresponding retinal points despite preserved motility. We present a case illustrating structural–functional correlation and targeted orthoptic management.

Tertiary university eye department with interdisciplinary postoperative retinal detachment follow-up and orthoptic collaboration.

A patient with acute macula-off rhegmatogenous retinal detachment (OD) complicated by proliferative vitreoretinopathy and epiretinal fibrosis underwent phacoemulsification with IOL implantation, pars plana vitrectomy, membrane peeling, endodrainage, cryopexy, intravitreal medication, and gas tamponade. Anatomical reattachment was achieved (VA 0.5). Three months postoperatively, persistent diplopia was reported. Orthoptic assessment showed full motility, small vertical phoria (4–6Δ), reduced stereopsis, alternating suppression on Worth 4-dot, and variable axis-dependent vertical diplopia. OCT demonstrated persistent macular remodeling.

A segmented vertical Fresnel prism was applied selectively over the symptomatic visual axis for near tasks. The patient reported immediate reduction of diplopia and improved functional visual comfort while maintaining binocular input. Symptoms were disproportionate to the small motor deviation, supporting a retinal sensory correspondence disturbance as the likely mechanism. The intervention remained adjustable and reversible.

Retinally mediated diplopia should be considered in patients following macula-off retinal detachment repair when symptoms exceed measured motor deviation and ocular motility is preserved. Structural–functional correlation is essential. Segmented Fresnel prism application may provide a practical and reversible rehabilitative option when conventional prism correction or occlusion is not tolerated.